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Research to rehab, simplified.
Hi there!
Katie, a 22 y/o female, came into the clinic with her mom for moral support. Just a few years prior, she began to experience horrible constipation following the near- loss of her Dad.
She dealt with the constipation on her own while navigating college life. But during her final semester, she began experiencing sharp, stabbing pain in her anus and bright red blood after bowel movements. Following weeks of attempts at conservative management, Katie underwent surgery to finally fix the stubborn anal fissure.
While the surgery helped the fissure to heal, Katie continues to experience constipation, painful bowel movements, and a fear of the fissure recurring. Her surgeon refers her to pelvic floor rehab to address the constipation and pain with defecation.
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Biofeedback efficacy for outlet dysfunction constipation, clinical outcomes and predictors of response by a limited approach
Italian researchers examined biofeedback outcomes in patients with refractory chronic constipation and who also failed a balloon expulsion test. They had two questions.
1. How effective is biofeedback across different types of outlet dysfunction?
2. Can simple clinical tools predict who will respond to treatment?
Methods
Inclusion criteria: 18+ years of age with a history of constipation lasting at least 1 year and met the Rome III criteria for functional constipation and/or IBS-C. (Side Note: this study was conducted around 2010, before the Rome IV criteria)
Exclusion criteria: History of abdominal surgery (excluding appendectomy, or cholecystectomy), eating or psychological disorders features of megarectum, megacolon or chronic intestinal pseudo obstruction, endocrine disorders (e.g. hypothyroidism or diabetes), regular use of known constipation-causing drugs
Measurements: Each participant answered a questionnaire for the Rome III Criteria for Functional Constipation/ IBS-C, a visual analogue scale (VAS) on their satisfaction with their bowel movements. In the same visit, participants also underwent anorectal manometry, a balloon expulsion test (BET), colonic transit time test, and two novel assessment tools:
1. A straining questionnaire asking patients which muscles they use to defecate with “abdominal muscles”, “anal muscles”, “both”, or “I don’t know/no answer” as possible responses.
2. An augmented digital rectal exam that included abdominal palpation during straining
Intervention:
First, all participants failed a four-week conservative treatment trial including fiber up to 30 grams a day, fluids, exercise, and limited laxative use.
After repeating measurements, participants completed five weekly biofeedback sessions that lasted 30 to 45 minutes each. The protocol included:
Teaching how to “strain more effectively” by coordinating expulsion efforts with their breath
Teaching how to relax the pelvic floor using intra-anal EMG feedback.
Practice defecating a 50ml air-filled balloon while a nurse provided gentle traction
One month after the last session, participants repeated the straining questionnaire, the Rome III symptoms questionnaire, the VAS, BET, the augmented digital rectal exam, and the anorectal manometry.
At six months after the last session, only the BET, VAS, and Likert were repeated.
Results:
At one month following the last treatment, 81 of the 131 participants (62%) responded favorably to biofeedback. To be considered a favorable response, researchers required both:
An increase of at least one complete spontaneous bowel movement per week
Subjective improvements on a Likert scale.
Participants classified as having dyssynergic defecation and inadequate defecatory propulsion also responded favorably, with response rates of 71% and 85%, respectively.
However, participants with structural outlet obstruction only experienced a 15% response rate.
Two things predicted who would respond best to biofeedback:
1. Participants who answered "anal muscles" on the straining questionnaire
2. Participants who didn’t use digital maneuvers to facilitate defecation. (These participants had an 82% response rate to treatment compared to the 36% of participants in those who used digital maneuvers).
After the study concluded:
almost 80% of participants reversed their Rome III dyssynergic defecation to normal on ARM
94% of participants with incomplete defecation had normalization of rectal pressure
62.6% of participants (82 of 131) had a negative BET.
At the 6 month follow-up, 80 of the 81 participants still had a negative BET.
Participants with co-morbid IBS-C maintained their improvements at six months follow-up.
What do we do with this information?
Patients with dyssynergic defecation and/or IBS-C will likely benefit from biofeedback as long as there is no structural obstruction.
Patients who think they need to use their “anal muscles” to push stool out are more likely to have success with biofeedback.
Look at other treatment options first in patients that have to use digital maneuvers to facilitate defecation.
Patients may need more than one biofeedback technique in order to provide different contexts to the brain and encourage motor learning.
Lambiase, C., Bellini, M., Whitehead, W. E., Popa, S. L., Morganti, R., & Chiarioni, G. (2025). Biofeedback efficacy for outlet dysfunction constipation: Clinical outcomes and predictors of response by a limited approach. Neurogastroenterology and motility, 37(1), e14948. https://doi.org/10.1111/nmo.14948
Applying the Findings
Treatment started with reducing pelvic floor tension through manual therapy, dry needling, and teaching Katie to use a pelvic wand (both vaginally and rectally).
From there, the focus then shifted towards re-education including:
education on posture with defecation
defecation technique (using the big belly, hard belly cue)
Biofeedback in the form of surface EMG focusing on pelvic floor relaxation, ultrasound biofeedback in a seated position focusing on lengthening, and practice lengthening her pelvic floor while sitting on a yoga ball or on her own hand
Respiratory muscle training (in case you missed it, click here).
After implementing these techniques, Katie could defecate without pain or straining 95% of the time. One month later, she was asymptomatic with defecation and improved bowel movement frequency.